1. Project design

1.1 Rationale

The population of the Netherlands is ageing rapidly. As the number of elderly people continues to grow, the number of people with multiple chronic conditions is also rising. Of those aged 65 and over, 7% live in care. More than 66,000 people currently reside in nursing homes. Of these, it is estimated that 36% suffer some kind of visual impairment. This means that visual information is extremely important, especially in the prevention of falls.

This practice-oriented research examines nursing home residents for visual impairments, as a means of prescribing the most effective adaptations. It also investigates whether the relevant healthcare records include information about eye care and if so what information is included.
Environmental factors in the home can reduce the risk of falls and lead to increased mobility. Improved lighting conditions and the effective use of colours can prevent falls in high-risk areas such as staircases and bathrooms. Quality of life can also be improved by means of optimized lighting and the use of contrast in the living environment.
The project 'In view of care’ focuses on identifying visual impairments among nursing home residents, the screening of healthcare dossiers to ascertain whether this issue is acknowledged and the development of resources to raise awareness and increase knowledge among healthcare professionals.

1.2 Objective

The project is important for residents, because an increased focus on poor vision can reduce the number of falls and increase residents’ quality of life. An evaluation of various subsidiary projects provides increased understanding and awareness among healthcare professionals of the eye care issues that
affect nursing homes. This will provide momentum for innovations in the field of eye care.

The project contributes to the quality of eye care provided in nursing homes by means of the following:

identifying visual impairments among nursing home residents;

screening and making adaptations to the immediate environment;

providing instruction and training to healthcare professionals in order to ensure that professional caregivers and family members have the tools they need to increase the quality of eye care in the nursing home;

using the knowledge and experience acquired from the project to develop resources to improve the quality of eye care in the nursing home. These resources will also be suitable for use nationwide.

1.3 Target group

nursing home residents with visual impairments;

healthcare professionals in the nursing home;

family members.

2. The project

As part of the project, the residents of four nursing homes were screened to identify eye conditions, visual impairments and to assess the general condition of their eyes. This screening or assessment of visual function (VF) was conducted by optometrists from Bartiméus, a Dutch organization for the blind and visually impaired. The living environment was assessed by means of an investigation of the lighting and photographic materials.

2.1 Research elements

The research involved four key elements:

An assessment of visual function (VF) among nursing home residents;

An investigation of healthcare records, focusing on eye conditions;

An investigation of the lighting in the nursing home environment;

An investigation of the living conditions of nursing home residents with visual impairments.

Figure 1 Research design in the four nursing homes

2.1.1 Assessment of visual function

The assessments of visual function were completed by optometrists from Bartiméus in August 2010. Up
to this point, the assessments were conducted on residents of several nursing homes in the Utrecht
region.
A total of 259 residents took part in the OZO project on the basis of informed consent. In terms of visual
acuity, 182 (=70%) of the residents examined did not suffer low vision according to WHO standards; 36
residents (14%) had low vision; and 12 (5%) had borderline low vision; 16 residents (6%) were blind. In
the case of 13 residents (5%), it was not possible to determine visual acuity.
Of the 259 residents examined, no referral was considered necessary for 141 (54%). A total of 118
residents were referred, generally because of cataracts.

2.1.2 Investigation of healthcare records

The healthcare records of the residents screened were analysed in terms of content in order to identify
whether any eye problems were mentioned and which other areas of concern were highlighted.

2.1.3 Investigation of the lighting in the living environment

Measurements, similar to those conducted previously by Aarts & Westerlaken (2005), were conducted
in order to identify the lighting situation in the living environment. These involved measurements of the
lighting intensity (horizontal and vertical) and colour temperature using the Konica Minolta
chromameter CL-200. These measurements were taken in the areas most commonly used by residents:
the living rooms and corridors.

2.1.4 Investigation of the living conditions of nursing home residents with visual impairments

The design of the living environment was investigated using photographic materials to identify the use
of colour and contrast in the design of corridors and living rooms and in everyday care, such as the
laying of tables.

2.2 Feedback to the departments

Contacts were maintained before and during the research with contact persons in each nursing home location and with specialists in geriatric care (nursing home doctors). The participating doctors were all members of the Steering Group established for this project. In consultation with contact persons and doctors, the results were presented in the form of a final presentation to staff in the nursing homes involved. The nursing homes were given the option of choosing one or several presentations. The locations in Driebergen and Utrecht opted for a single presentation and those in Maarssen and Zeist chose two presentations; one for physical healthcare/rehabilitation departments and one for psycho-geriatric departments. The VFO reports were sent to the specialists in geriatric medicine via the contact persons within two weeks of completion of the assessments by the Bartiméus researchers.

2.3 Conclusion

The project was concluded on 20 January 2011 with a final symposium.
The programme included the following presentations:

Why do people with low vision see poorly? Dr C.A. Verezen, Chairperson, OVN (Netherlands Optometrists Association)
Poor visual acuity is often incorrectly considered to be a synonym for ‘poor vision’. Visual acuity often provides an insufficient explanation of why people claim to be unable to make out or see things. Inadequate light, deteriorating contrast sensitivity and a limited field of vision can also have an important negative impact on visual functioning. But these problems do not only affect people with eye diseases: elderly people with normal healthy eyes also often have visual impairments. This presentation discusses visual impairments with measurable loss of function and with no measurable loss of function.

Lighting and Biorhythms T. Schoutens RN, Davita Nederland BV
Almost all bodily functions and behaviour operate according to a rhythm of approximately 24 hours. Although rarely considered, these biorhythms are essential for our well-being. A biological clock that functions properly ensures that the day/night rhythms in important bodily functions are in line with the everyday light/dark cycle in the outside world. This clock needs to be regularly reset and uses a number of signals from other parts of the body to achieve this. The most important signal comes from the retina in the eye. As people grow older, the retina becomes less effective in passing on these signals and the sleep/waking rhythm becomes unbalanced. This results in anxiety and restlessness in the late afternoon and evening and apathy during the day. Exposure to sufficient light during the day and a lot of darkness during the night helps to stabilize this rhythm, improve behaviour and promote the welfare of elderly people for a specific period.

Poor vision in the nursing home G. Koevoets, Bartiméus
Brief explanation of the options for research, advice and support and the results based on practical examples in the nursing home.

Lighting in the nursing home Dr J. van Hoof, researcher at HU
In the nursing home of the future, lighting, light and daylight will play a major role. Research in the Netherlands has shown that many homes for the elderly in the country are too dark for good vision and for enabling light to have its biological impact on people. Progress can be made with the right lighting solutions. This presentation examines lighting for the elderly and what it can achieve.

Results of ‘In view of care’ M. Sinoo, researcher at HU
This presentation highlights the project results collected in the period January 2009 to August 2010 in
the four nursing homes studied. The results relate to the outcomes of the visual function assessments conducted on 259 nursing home residents in alliance with Bartiméus. There will then be a discussion of the analysis of healthcare records for eye care information, followed by the light and environment investigation. The resources developed during the project will then be shown.

This final presentation closed the symposium and the OZO project.

Final results
Within the nursing homes/care groups, the knowledge acquired was combined to create the following products:

for nursing home residents:
A report of the eye examination, possibly also including referral to an optician or monitoring of eye conditions, additional focus, support (tools and help in the use of light) and effective everyday eye care.

for healthcare professionals:

- The Digital teaching materials Visual Impairments in the Nursing Home to increase knowledge of poor vision;
- The DVD In View of Care with recordings of problem scenarios that can occur in the nursing home involving residents with poor vision.

Knowledge was disseminated nationally and internationally by means of the following: